Ten hours and 59 minutes into the new year, the Milwaukee Fire Department dispatched an engine to an apartment on the city's west side: A mother woke moments before beside her unresponsive infant son.
Twelve minutes later, the dispatcher called the Milwaukee County Medical Examiner's Office.
The boy was dead.
Malachi was born less than wo months earlier, Nov. 11, 2010, his mother's 14th birthday. The mother told a medical investigator she spent New Year's Eve at church and in the morning found Malachi facedown beside her in a twin-size bed.
Malachi was one of 35 sleep-related deaths in Milwaukee in the 30-month period that ended June 30.
Others include 2-month-old Gregory, who died while sleeping in a car seat as his 15-year-old mother slept on a bunk bed nearby. And Angelina, also 2 months, who died facedown in a bassinet, a set of safe-sleep guidelines printed on the sheet. And David, 12 days old, who suffocated in a filthy home beside his mentally ill mother who had fallen asleep while breast-feeding him on a makeshift bed of couch cushions.
In Milwaukee, which has one of the nation's highest infant mortality rates, premature birth is the leading killer of babies before their first birthday. But most of those deaths happen in the first month of life.
Over the next 11 months, sleep-related deaths -- sudden infant death syndrome, suffocation while sleeping with an adult, asphyxiation from being wedged in the cushions of a couch -- take the lead.
As the city works toward its newly set goal of driving the infant mortality rate to historic lows by 2017, a reduction of sleep-related deaths is a promising opportunity and vexing challenge. Eliminate the deaths entirely, and -- if other factors stay the same -- the goal is met.
The causes of prematurity are many and complex: poverty, access to health care, stress, poor health practices. But the risk factors tied to sleep-related deaths are known and in most cases easy to abate.
A safe sleep environment can be summed up as simply as ABC: Infants are safest when placed to sleep Alone, on their Backs, in a Crib free of blankets, pillows or other soft objects.
"Safe sleep is the low-hanging fruit on the prevention tree," said Jason A. Jarzembowski, director of perinatal pathology at Children's Hospital of Wisconsin.
Despite the city of Milwaukee's ongoing and aggressive safe-sleep campaign, babies continue to die.
In the months that followed Malachi's death, six more Milwaukee infants died this year after sleeping with an adult or another child: Harmony, Brielle, Davion, Reneja, Demirrion and Ashley.
Two others died in what experts consider unsafe sleep conditions: Illie was found facedown on a pillow in his crib; Jordan had been placed to sleep on a leather couch.
Case by case
The Journal Sentinel examined the medical examiner's reports for all 35 sleep-related deaths in Milwaukee in the 2 1/2-year period ending June 30 and compared each case against newly published safe-sleep recommendations by the American Academy of Pediatrics.
The review focused on eight modifiable risks -- that is, ones parents can do something about: sleep position, sleep surface, bed-sharing, soft objects and loose bedding, irregular prenatal care, exposure to smoke, caregiver alcohol or drug use and lack of breast-feeding.
The majority of infants died while exposed to multiple risks. No deaths occurred without the presence of at least one risk factor, and only one death occurred with just a single risk. At least four risk factors and as many as seven were present in three-quarters of the 35 deaths.
In 70 percent of all cases, clusters of risk were associated with an unsafe sleep environment, such as bed-sharing or use of an unsafe sleep surface. In 60 percent of the unsafe environment cases, investigators noted the presence of unused cribs in the house.
Researchers cannot, with certainty, weigh the risk of any particular factor. Nor is it well understood how the factors relate to each other.
That is because the rate at which the risks are being taken in the general population is unknown. We don't know how many children sleep in adult beds or how many babies do not breast-feed or how many babies who are not breast-fed are put to sleep in adult beds.
What is known is what risk factors are present when a baby dies.
"The presence of a risk factor does not always mean it caused death," said Rachel Y. Moon, a pediatrician at the Children's National Medical Center in Washington, D.C., and the lead author of the pediatric academy's updated safe-sleep recommendations.
Some children, Moon said, are especially susceptible to sudden infant death. Some are especially resilient.
"Then you have the 90 percent in between," she said.
Prevalence of SIDS
The most common cause of sleep-related death, here and nationwide, is SIDS.
In Milwaukee, during the 30-month period examined by the Journal Sentinel, nearly three times as many babies died of SIDS as of the next leading cause.
SIDS is defined by the Centers for Disease Control and Prevention as "the sudden death of an infant less than one year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history."
"It is a diagnosis of exclusion," said Milwaukee County Medical Examiner Brian Peterson.
Parents around the country whose children have died of SIDS say not knowing how or why their baby died deepens their suffering and stigmatizes them in the eyes of people who assume that, without a medical explanation, the parents must somehow be responsible.
"No matter what they think, we're still parents of a dead child," said Steven Stuart, whose 2-month-old son, Colin, died March 2.
"It hurts just as bad. We just don't have an answer to: 'Why?'"
Stuart, who lives with his wife, Ellen, and their 4-year-old daughter in Greenbelt, Md., is a frequent contributor to the blog "Grieving Dads Project," and the author of his own blog, "Colin's Corner."
Colin, born three weeks early, was a small baby -- 4 pounds, 13 ounces. He was so skinny and wrinkly that a friend called him Benjamin Button, the fictional character who was born old and became younger with age. The nickname "Button" stuck.
Stuart had just finished feeding his son a bottle of breast milk. Colin was lying face up on Stuart's chest. Stuart was watching television. Colin stopped breathing.
Stuart jumped to his feet. He and his wife called 911, tried to revive their son and waited for the rescue workers to come.
Ellen Stuart went with Colin to the hospital while Steven Stuart stayed home, talking to the police. He was still talking to them, holding his daughter, when his wife called to say Colin was dead.
It was four months before a medical examiner could make official an initial diagnosis of SIDS. The diagnosis did nothing to ease Stuart's guilt and pain. "As a father, your job is to provide and protect," he said. "You feel like you failed."